Fusion of memristor and digital compute-in-memory processing for energy-efficient edge computing

Artificial intelligence (AI) edge devices prefer employing high-capacity nonvolatile compute-in-memory (CIM) to achieve high energy efficiency and rapid wakeup-to-response with sufficient accuracy. Most previous works are based on either memristor-based CIMs, which suffer from accuracy loss and do not support training as a result of limited endurance, or digital static random-access memory (SRAM)-based CIMs, which suffer from large area requirements and volatile storage. We report an AI edge processor that uses a memristor-SRAM CIM-fusion scheme to simultaneously exploit the high accuracy of the digital SRAM CIM and the high energy-efficiency and storage density of the resistive random-access memory memristor CIM. This also enables adaptive local training to accommodate personalized characterization and user environment. The fusion processor achieved high CIM capacity, short wakeup-to-response latency (392 microseconds), high peak energy efficiency (77.64 teraoperations per second per watt), and robust accuracy (<0.5% accuracy loss). This work demonstrates that memristor technology has moved beyond in-lab development stages and now has manufacturability for AI edge processors.

Prognostic factors for recurrence-free survival in resected pathologic N2-stage III non-small cell lung cancer treated with upfront surgery

BACKGROUND

The standard treatment for pathological N2 (pN2) non-small-cell lung cancer (NSCLC) patients is definitive chemoradiation. Surgery might be beneficial for resectable pN2 disease, so we investigated the recurrence-free interval of upfront surgery for selected patients with resectable pN2 disease.

METHODS

The clinicopathologic characteristics of patients with pN2 NSCLC who underwent upfront anatomical resection at Taipei Veterans General Hospital from 2011 January to 2019 December were retrospectively reviewed. A Cox regression model was used to identify prognostic factors of recurrence-free survival (RFS).

RESULTS

In total, 84 patients after curative lung anatomic resection were analyzed, with a 44-month median survival. The 1-, 3-, and 5-year RFS rates were 63.1%, 31.3%, and 19.9%, respectively, with a median RFS of 18.9 months. Multivariable cox regression analysis identified that the significant predictor for RFS was a tumor size of more than 3 cm (hazard ratio [HR] = 1.74, 95% CI, 1.07-2.83, p = 0.027). Visceral pleural invasion, LN harvest number, tumor stage, and N2 status including single zone (N2a) or multiple zones (N2b) were not prognostic factors in this study.

CONCLUSION

Upfront surgery for resectable N2 disease achieved favorable outcomes in selected patients, especially better recurrence control with limited tumor size. Therapeutic advances might encourage surgeons to aggressive intervention.

Impact of frailty on the short-term outcomes of elderly intensive care unit patients

BACKGROUND

Frailty leads to multiple unfavourable outcomes in older adults. However, few studies have investigated correlations between frailty and its impacts on morbidity and mortality of elderly patients in intensive care units (ICUs) in Taiwan.

AIMS

To investigate the impact of frailty on the risk of hospital and 30-day mortality and functional outcomes of elderly Taiwanese ICU patients.

STUDY DESIGN

A prospective observational study was conducted. Patients aged 65 years or older were recruited from three medical ICUs. We defined 'frailty' according to the Clinical Frailty Scale (CFS) higher than 4 within 1 month prior to admission. The primary outcomes were hospital and 30-day mortality. The secondary outcome was CFS changes at ICU admission, hospital discharge, and 30-day follow-up. Logistic/Cox regression was used to analyse the data.

RESULTS

We recruited a total of 106 patients, 57 (54%) of whom were classified as frail. The overall mortality rate was 21%. Hospital mortality and mortality within 30 days after discharge were higher in the frail patients without a significant statistical difference (hospital mortality: 17.5% vs. 12.2%, p = .626; 30-day mortality: 26.3% vs. 14.3%, p = .200). The risk of 30-day mortality for frail patients was up to 2.84 times greater than that of non-frail patients in the Cox model (hazard ratio = 2.84, 95% confidence interval [0.96, 8.38]). Both non-frail and frail patients had a worse CFS score on admission, but the CFS score of surviving non-frail patients improved significantly over the medium term.

CONCLUSION

Frailty tended to increase short-term ICU mortality risk and worsen functional outcomes in the elderly Taiwanese population. This information might guide critical medical decisions.

RELEVANCE TO CLINICAL PRACTICE

Frailty could be included in the prognostic evaluation of either mortality risk or functional outcome. Prompt palliative care might be one last piece of holistic elder care.

Decreasing the incidence of central line-associated bloodstream infection in a medical intensive care unit: a best practice implementation project

INTRODUCTION AND OBJECTIVES

Bloodstream infections are common in critically ill patients using central venous access devices (CVAD) in intensive care units (ICU). This project aimed to decrease the incidence of central line-associated bloodstream infections (CLABSI) by using evidence-based strategies.

METHODS

The project applied the JBI audit and feedback methods. Thirty-two nurses and five resident physicians from the medical ICU of a medical center participated in the project. Preintervention compliance was measured for the 11 key evidence-based criteria (six audit criteria of central venous catheter insertion and five audit criteria of dressing and catheter securement). Strategies were implemented to overcome the barriers identified in the baseline assessment. Impact evaluation and sustainability were conducted to change the CLABSI rate and the competence of healthcare professionals in providing CVAD care. The JBI Practical Application of Clinical Evidence System and Getting Research into Practice audit tools were used for the data collection, analysis, and implementation planning.

RESULTS

Barriers included insufficient knowledge among nurses and physicians, poor compliance with the standard CVAD insertion procedure by physicians, inadequate cooperation among the CVAD care team members, and lack of CVAD-related equipment. The strategies included education and training in CVAD care, the establishment of a team resource management program, and the provision of appropriate equipment. Following project implementation, the CLABSI rate decreased from 8.38 to 3.9 BSIs/1000 CVAD-days.

CONCLUSIONS

The project successfully decreased the CLABSI rate and increased the competence of healthcare professionals. Implementation of best practices in clinical care should focus on leadership, team resource management, education, monitoring, and innovation.

Outcomes of patients with different lepidic percentage and tumor size of stage I lung adenocarcinoma

Background

To evaluate the long‐term outcomes after surgical resection for stage I lung adenocarcinoma based on the percentage of lepidic component (LC) and invasive tumor size (IS).

Methods

The clinicopathological characteristics of 1049 patients with stage I lung adenocarcinoma who underwent surgery between 2006 and 2016 were retrospectively reviewed. Tumors were categorized into groups: A (LC ≥ 50%) and B (LC < 50%). Groups A0 and A1 consisted of minimally invasive adenocarcinomas (MIA) and other lepidic‐predominant invasive adenocarcinomas, respectively. Group B was categorized into B1 (IS ≤ 1 cm), B2 (1 < IS≤2 cm), and B3 (2 < IS≤3 cm) by invasive tumor size and divided into subgroups (B1[lep+]/[lep−], B2[lep+]/[lep−], and B3[lep+]/[lep−]) according to the presence[lep+] or absence[lep−] of LCs. Cumulative incidence of recurrence (CIR) and cancer‐specific survival (CSS) were examined.

Results

LC decreased with increasing IS. Only 24 (8.5%) tumors in group A had an IS >1 cm. 10‐year CIR and CSS were 15.2% and 86.0%. LC and IS were found to be independent predictors of CSS. Patients in group A had 1.4% 10‐year CIR and 100% 10‐year CSS. In group B, a significantly higher CIR and worse CSS were observed as IS increased (p < 0.001), but LC was not a predictor for CSS (p = 0.593). No significant differences in CIR or CSS were found in presence of LC or not when LC < 50% (B1[lep+]/[lep−], B2[lep+]/[lep−], and B3[lep+]/[lep−]: p = 0.36/0.48, p = 0.82/0.94, and p = 0.90/0.37, respectively).

Conclusions

LC≥50% tumors demonstrated excellent prognosis regardless of IS. The outcomes of LC < 50% tumors were well predicted by IS, corresponding to the T‐staging system. The predictive value of LC for prognosis became insignificant.

Preoperative consolidation-to-tumor ratio is effective in the prediction of lymph node metastasis in patients with pulmonary ground-glass component nodules

BACKGROUND

Preoperative positron emission tomography/computed tomography (PET/CT) is recommended as a guideline for staging of lung cancer. However, for patients with pulmonary ground-glass opacity (GGO) nodules who are supposed to have a relatively low risk of incidence of lymphatic metastasis, it remains uncertain whether PET/CT is more effective than consolidation-to-tumor ratio (CTR) in the prediction of regional lymphatic metastasis.

METHODS

The data on patients who underwent surgery for lung cancer from 2011 to 2016 were collected retrospectively, which included CTR, results of PET/CT, and pathological characteristics. The patients who had undergone preoperative PET/CT were identified to find the risk factors for lymphatic metastasis. A receiver operating characteristic (ROC) curve and multiple logistic regression was utilized to clarify the predictive value of CTR and main tumor maximal standardized uptake value (SUVmax).

RESULTS

Among 217 patients who had PET/CT before lobectomy, chest computed tomography revealed that 75 patients had CTR greater than 62%. The patients with lymphatic metastasis were shown to have higher CTR and higher main tumor SUVmax. Multiple logistic regression showed that younger age (<60 years), higher main tumor SUVmax on PET/CT, and greater CTR were independent predictive factors for lymphatic metastasis. The area under the ROC curve was comparable, 0.817 for CTR, and 0.816 for main tumor SUVmax.

CONCLUSIONS

The present study revealed that CTR was not inferior to main tumor SUVmax considering the predictive power for lymphatic metastasis preoperatively in lung cancer patients with a GGO component. PET/CT might not be necessary preoperatively in selected patients.

Significance of preoperative biopsy in radiological solid-dominant clinical stage I non-small-cell lung cancer

OBJECTIVES

The present study aimed to clarify the association between preoperative biopsy and surgical outcomes in clinical stage I non-small-cell lung cancer (NSCLC) with different proportions of ground-glass opacity (GGO).

METHODS

Data on patients who underwent pulmonary resection for NSCLC from 2006 to 2016 were drawn from a prospective registered database and analysed retrospectively. Patient characteristics collected included tumour size, location and staging, surgical approach, consolidation-tumour ratio, histopathology and the presence or absence of preoperative biopsy to identify the independent prognostic factors of disease-free survival (DFS) and cancer-specific survival. A 1:1 propensity score matching was conducted between the preoperative biopsy and reference groups based on their baseline characteristics measured before the decision for preoperative biopsy.

RESULTS

A total of 1427 patients were collected to achieve an overall 5-year DFS as 84.5% (median follow-up: 67.3 months), stratified to be 99.5% in the GGO-dominant group (n = 430) and 78.2% in the solid-dominant group (n = 997). Only 2 patients (0.5%) in the GGO-dominant group experienced tumour recurrence. For solid-dominant tumours matched with propensity scores (279 in preoperative biopsy vs 279 in reference group), the independent predictors of DFS included preoperative biopsy, sublobar resection, pathological staging and angiolymphatic invasion. Preoperative biopsy was a predictor of cancer-specific survival in univariable analysis but was not in multivariable analysis. Significant differences were also found between matched groups in those with late-delay surgery, but not in patients receiving preoperative biopsy with early-delay surgery (≤21 days).

CONCLUSION

Preoperative biopsy may worsen surgical outcomes in patients with clinical stage I, solid-dominant NSCLC.

Ascending aorta replacement vs. total aortic arch replacement in the treatment of acute type A dissection: a meta-analysis

OBJECTIVE

Acute type A aortic dissection (ATAAD) is a severe, rapidly progressing disease which typically requires patients to undergo emergency surgical intervention. Despite advancements in surgical procedures, still, ATAAD remains a surgical emergency associated with high mortality. The aim of this systematic review and meta-analysis was to compare whether either ascending aorta replacement (AR) or total aortic arch replacement (TR) leads to improved short- and long-term clinical outcomes.

MATERIALS AND METHODS

A search of PubMed, Embase, Science Direct, Web of Science, SciELO, BIOSIS, and China National Knowledge Infrastructure (CNKI) databases were supplemented by searching through bibliographies of key articles. Thereafter, data on early and late prognostic factors were extracted. A systematic review and meta-analysis of 15 studies were performed to compare whether either AR or TR leads to a reduction in the risk of in-hospital and short-term mortality, postoperative complications, re-operation rate, and long-term mortality.

RESULTS

A total of 15 cohort studies (n = 2822 patients with ATAAD; AR with HA, partial arch = 1911, TR = 911) were deemed eligible and included in the meta-analysis. Compared with TR, AR led to a significantly lower risk of in-hospital mortality (RR = 0.77; 95% CI: 0.61-0.96), shorter cardiopulmonary bypass time (CPB, mean difference = -53.09; 95% CI: -56.68--49.50), circulatory arrest time (CA, mean difference = -8.09; 95% CI: -9.04-7.15), and antegrade cerebral perfusion (ACP, mean difference = -28.62; 95% CI: -30.23--27.00). Differences in the incidence rates of neurological dysfunctions and renal dialysis were not significant. The pooled rate of aortic re-operation was lower in TR group (AR 7.6% vs. TR 5.3%), albeit not significantly (risk ratio = 1.39; 95% CI: 0.94-2.07; p = 0.10).

CONCLUSIONS

These findings demonstrate that AR is associated with a lower early mortality rate and shorter operative times overall. Nevertheless, the incidence of postoperative complications in patients undergoing AR is comparable to that of patients undergoing TR. Further prospective follow-up data needs to be collected and analyzed to discern whether there are statistically significant differences in the risks of re-operation and long-term mortality between AR and TR procedures.

Developing a Competency-Based Learning and Assessment System for Residency Training: Analysis Study of User Requirements and Acceptance

BACKGROUND

The increasingly complex medical environment highlights the importance of milestones and entrustable professional activities (EPAs) to realize the ideals of competency-based medical education (CBME). However, if enormous amounts of assessment results need to be compiled, the development of a digital system to manage, integrate, and synthesize learning and assessment data will be necessary. Furthermore, this system should be able to facilitate real-time assessment with feedback and therefore enhance users' learning through coaching in the moment in the clinical workplace.

OBJECTIVE

The main purpose of this study was to develop a competency-based electronic platform system to provide resident physicians with clinical assessments and learning in order to enhance the learning of trainees and reduce the burden of assessments.

METHODS

A competency-based learning and assessment system (CBLAS) for residency training was designed, developed, and evaluated in this study. Opinion interviews and a focus group consensus meeting of key users, including trainees, clinical teachers, and administrative staff, were conducted as needs assessments. The structure of the CBLAS was designed according to the thematic analysis of needs assessments. Clinical teachers' acceptance of using CBME assessments, according to the constructs of attitude, perceived usefulness, and perceived ease of use, was surveyed in the beginning and half a year after implementation of the CBLAS. Additionally, the satisfaction of using the CBLAS, according to information, system, and service qualities, was surveyed after implementation.

RESULTS

The main functions of the CBLAS, including milestones, EPAs, learning portfolios, teacher/student feedback, e-books, learning materials, assessment progress tracking, and statistical analysis of assessment results, were designed and developed for responding to nine themes, which emerged from the needs assessments of the three user groups. Twenty clinical teachers responded to the CBME assessment acceptance surveys before and after CBLAS implementation, which revealed a significant improvement in the factor of "attitude" (P=.02) but no significant differences in the two factors of "usefulness" (P=.09) and "ease of use" (P=.58) for CBME assessments. Furthermore, satisfaction surveys were performed in 117 users, and 87.2% (102/117) were satisfied with the CBLAS in terms of information, system, and service qualities. There was no significant difference in satisfaction among different user groups.

CONCLUSIONS

The CBLAS is a user-centered platform that supports clinical teachers' assessment exercises and residents' learning, as well as administrative work for staff according to users' needs assessments and operationalized features of CBME assessments. With the system, clinical teachers had a more positive attitude to conduct the assessment activities of milestones and EPAs and learners could arrange their study schedules to enhance their learning effectiveness. The CBLAS sheds light on how to effectively design and develop a digital system to execute milestone- and EPA-based assessments for enhancing competency-based education among residents, according to our experiences in Taiwan.

Clinical, pathophysiologic, and genomic analysis of the outcomes of primary head and neck malignancy after pulmonary metastasectomy

The median overall survival (OS) of some head and neck malignancies, such as head and neck squamous cell carcinoma (HNSCC), with metastatic lesions was only 12 months. Whether aggressive pulmonary metastasectomy (PM) improves survival is controversial. Patients with primary head and neck malignancy undergoing PM were enrolled. Clinical outcomes were compared among different histological types. Whole-exome sequencing was used for matched pulmonary metastatic samples. The genes where genetic variants have been identified were sent for analysis by DAVID, IPA, and STRING. Forty-nine patients with primary head and neck malignancies were enrolled. Two-year postmetastasectomy survival (PMS) rates of adenoid cystic carcinoma, thyroid carcinoma, nasopharyngeal carcinoma, and HNSCC were 100%, 88.2%, 71.4%, and 59.2%, respectively (P = 0.024). In HNSCC, the time to distant metastasis was an independent predictive factor of the efficacy of PM. Several pathways, such as branched-chain amino acid (BCAA) consumption, were significantly associated with the progression of HNSCC [P < 0.001, fold enrichment (FE) = 5.45]. Moreover, metabolism-associated signaling pathways also seemed to be involved in cancer metastasis. Histological types and time to distant metastasis were important factors influencing the clinical outcomes of PM. For HNSCC, metabolic-associated signaling pathways were significantly associated with tumor progression and distant metastasis. Future validations are warranted.

Clinical relevance of PD-L1 and PD-L2 overexpression in patients with esophageal squamous cell carcinoma

Background

Even with the advance of diagnosis and the treatment, the 5-year survival rate for esophageal cancer patients is still poor. The checkpoint protein inhibition provides another choice to improve the survival. The expression of the programmed death ligand-1 (PD-L1) was reported but the clinical relevance remained inconsistent in esophageal cancer. Besides, there were few references about the other ligand, programed death ligand-2 (PD-L2). In this study, we evaluated the expressions of PD-L1 and PD-L2 in patients with esophageal squamous cell carcinoma (ESCC) and assessed their clinical relevance.

Methods

From 1996 to 2011, 150 patients undergone complete surgical resection for ESCC were enrolled. Clinical data were recorded. Expression of PD-L1 and PD-L2 on cytoplasm in paraffin embedded tumor samples were analyzed by immunohistochemistry staining and scored with a semi-quantitative method.

Results

Of the patients, 96 (64.0%) patients had PD-L1 overexpression and 63 (42.0%) had PD-L2 overexpression. There was a correlation between the expression of PD-L1 and PD-L2 (P<0.001). Patients without overexpression of PD-L1, pathological T1-2 and N0 status, pathological stage I-II and no post-operative adjuvant treatment had a better disease free survival (DFS). In multivariate analysis, PD-L1 expression and pathological stage were the independent prognostic factors for DFS. The expression of PD-L2 did not influence the DFS. Although not statistically significant, patients without overexpression of PD-L1 and PD-L2 seem to have a better overall survival (OS).

Conclusions

The overexpression of PD-L1 on cytoplasm, not PD-L2, is an independent prognostic factor for DFS in patients with ESCC undergone esophagectomy. However, there is a trend which suggested that patients without overexpression of PD-L1 and PD-L2 had a better OS.

Tubeless single-port thoracoscopic sublobar resection: indication and safety

Background

The tubeless technique, defined as non-intubated general anesthesia with omission of chest drainage after video-assisted thoracoscopic surgery (VATS), is a new concept to further minimize surgical trauma. However, there has been little investigation into the associated feasibility and safety. Minimization of postoperative pneumothorax is challenging. We set up a "tubeless protocol" to select patients for tubeless single-port VATS with monitoring of a digital drainage system (DDS).

Methods

From November 2016 to September 2017, 50 consecutive non-intubated single-port VATS for pulmonary resection were performed. In our study, patients with small and peripheral pulmonary lesions indicated for sublobar resections, as diagnostic or curative intent, were included. After excluding patients having tumors >2 cm, or intrapleural adhesions noted during operation, or forced expiratory volume in the 1 second <1.5 L, 36 patients were selected for tubeless protocol. The clinical characteristics and perioperative outcomes of these patients are presented.

Results

Among 36 cases, 5 patients had minor air leaks detected using the DDS and required intercostal drainage after wound closure. Among the remaining 31 patients in whom the DDS showed no air leak, the chest drainage was removed immediately after wound closure. A postoperative chest roentgenogram on the surgery day showed full expansion in all patients without pneumothorax. Only 7 (19.4%) patients developed minor subclinical pneumothorax on the first postoperative day without the need for chest drainage. All patients were discharged uneventfully without the need for intervention.

Conclusions

Our tubeless protocol utilizes DDS to select patients who can have intercostal drainage omitted after non-intubated single-port VATS for pulmonary resection. Using objective DDS parameters, we believe that this is an effective way to reduce the rate of pneumothorax after tubeless single-port VATS in selected patients.

Clinical relevance of cell-free DNA in gastrointestinal tract malignancy

BACKGROUND

Cell-free DNA (cfDNA) extracted from blood has become a clinically feasible biomarker in various types of cancer. However, the clinical significance of cfDNA in gastrointestinal (GI) tract cancer among Asian populations requires further investigation.

RESULTS

The median cfDNA copy number was highest in esophageal cancer, followed by colorectal cancer and gastric cancer, which were all significantly higher than those of healthy individuals. The cfDNA levels were higher in GI tract cancer, followed by those in carcinoma in situ and then healthy individuals (P = 0.019). During the postoperative surveillance, the cfDNA level tended to be more sensitive than the carcinoembryonic antigen level in predicting recurrence. For recurrent gastric cancer, a persistently high cfDNA level and an increasing trend was observed after surgery. For stage IV colorectal cancer, dynamic changes in the cfDNA level were correlated with the responses to chemotherapy and surgery.

MATERIALS AND METHODS

Blood samples were collected from 95 healthy individuals and from 855 patients diagnosed with GI tract malignancy, including 98 with esophageal cancer, 428 with stomach cancer, 329 with colorectal cancer and 30 with carcinoma in situ. The copy numbers of extracted cfDNA were analyzed and compared among the different types of GI cancers.

CONCLUSIONS

The cfDNA level can serve as a feasible biomarker for detecting tumors in GI tract cancer. The cfDNA level may play a role in predicting tumor responses to chemotherapy and surgery in colorectal cancer; tumor recurrence should be considered in gastric cancer with a persistently high cfDNA level after surgery.

Correction: Long term oncological outcome of thymoma and thymic carcinoma - an analysis of 235 cases from a single institution

[This corrects the article DOI: 10.1371/journal.pone.0179527.].

Long term oncological outcome of thymoma and thymic carcinoma - an analysis of 235 cases from a single institution

BACKGROUND AND OBJECTIVES

Thymoma has a variable long-term oncological outcome after surgical resection. Survival and tumor recurrence were analyzed to determine the predisposing factors for tumor recurrence.

METHODS

A total of 235 patients who underwent surgery for thymoma or thymic carcinoma from December 1997 to March 2013 were analyzed using Masaoka staging system and World Health Organization (WHO) histological classification. Surgical intervention included extended thymothymectomy via median sternotomy and thymomectomy via thoracotomy/ video-assisted thoracoscopic surgery (VATS).

RESULTS

The median duration of follow-up was 105 months (12-198 months). Among these 235 patients, recurrence was observed in 25 patients (10.7%). according to Masaoka stage I, IIA, IIB, III, IVA, IVB, recurrence rates were 1/65(1.5%), 8/106(7.5%), 1/32(3.1%), 6/20(30.0%), 8/10(80.0%), 1/1(100.0%), respectively. Disease or treatment-related mortality was observed in 13 patients. Overall survival rate was 94.4%. After univariate analysis, predisposing factors for tumor recurrence included Masaoka stage, WHO histologic type, tumor size, adjuvant therapy and margin status.

CONCLUSIONS

Due to the indolent behavior of thymoma, tumor recurrence appears to be a better assessment of oncological outcome rather than survival. Factors associated with tumor recurrence include Masaoka stage, WHO histologic type, tumor size, adjuvant therapy and margin status.

Surgical outcomes of pulmonary mucoepidermoid carcinoma: A review of 41 cases

INTRODUCTION

Pulmonary mucoepidermoid carcinoma is a rare cancer that occurs primarily in younger patients. The prognostic factors of pulmonary mucoepidermoid carcinoma are largely undetermined, especially in elderly patients. The aim of this study was to examine the clinical characteristics and prognostic factors influencing survival after surgical resection in patients with pulmonary mucoepidermoid carcinoma and also analyze the clinical manifestations and prognostic factors in elderly patients.

MATERIALS AND METHODS

The pathological records of 41 pulmonary mucoepidermoid carcinoma patients (mean age, 61.4 years) who underwent surgical resection at our hospital between January 1991 and July 2015 were retrospectively reviewed. Subjects >65 years of age (n = 22) were considered elderly.

RESULTS

The median follow-up duration was 42.9 (interquartile range, 15.0-120.8) months. Sixteen patients (39.0%) experienced tumor relapse, including 13 patients (81.3%) within 2 years. The 5-year disease-free survival rate was 57.9%. Tumor grade did not influence disease-free survival (P = 0.286). In the multivariate analysis, age, tumor size, pathological T3-4 status, and pathological N2 status were independent predictors of disease-free survival. The 5-year overall survival rate was 57.0%. Tumor grade also did not influence overall survival (P = 0.170). Age, tumor size, pathological T status, and pathological N2 status were independent predictors of overall survival. In elderly patients, the 5-year disease-free survival and overall survival rates were 41.4% and 41.5%, respectively. Pathological T status was the only independent predictor of both disease-free survival and overall survival in elderly patients.

CONCLUSIONS

Prognostic factors identified for pulmonary mucoepidermoid carcinoma in this study differ from those of previous studies. Principally, tumor grade did not influence either disease-free survival or overall survival. Age, tumor size, and pathological factors were independent predictors of disease-free survival and overall survival. In elderly patients, pathological T status was the only independent predictor of disease-free survival and overall survival.

Prognostic histological factors in patients with esophageal squamous cell carcinoma after preoperative chemoradiation followed by surgery

Background

Pathological response is an important marker for tumor aggressiveness in patients with esophageal squamous cell carcinoma (ESCC) who receive preoperative chemoradiation followed by esophagectomy. We aim to evaluate the prognostic value of histological factors after trimodality treatments.

Methods

91 patients who received preoperative chemoradiation followed by transthoracic esophagectomy between 2009 and 2014 were included. The pathological examination was reviewed. Overall survival and disease free survival were recorded. Survival analysis was performed using the Cox regression model, and the survival curves were compared by the log-rank test.

Results

Survival analysis showed lymphovascular invasion (LVI, hazard ratio [HR]: 2.009, p = 0.029), perineural invasion (PNI, HR: 2.226, p = 0.019), ypN stage (HR: 2.041, p = 0.019), extracapsular invasion (ECI, HR: 2.804, p = 0.003), and incomplete resection (HR: 1.897, p = 0.039) as unfavorable prognostic factors affecting overall survival (OS). Moreover, tumor regression grade (TRG, HR: 1.834, p = 0.038), LVI (HR: 1.975, p = 0.038), ECI (HR: 2.836, p = 0.003), and incomplete resection (HR: 2.254, p = 0.007) adversely affected disease-free survival (DFS). Prognostic classification based on poor primary tumor (TRG2/3, LVI(+), and PNI (+)), lymph node (ypN(+) and ECI(+)), and surgical (incomplete resection) factors significantly predicts OS (p = 0.013) and DFS (p = 0.017). However, the use of postoperative adjuvant therapy was not a significant prognostic factor even in medium- and high-risk ESCC patients who underwent trimodality treatments.

Conclusions

Histological factors, including primary tumor, lymph node, and surgical factors has high prognostic value for predicting outcomes in ESCC patients receiving preoperative chemoradiation followed by surgery.

A Cohort Study of Adult Patients with Severe Dengue in Taiwanese Intensive Care Units: The Elderly and APTT Prolongation Matter for Prognosis

Background

There was a large dengue outbreak in Taiwan in 2015, in which the ages of the affected individuals were higher than those in other countries. The aim of this study was to explore the characteristics and prognostic factors for adults with severe dengue in intensive care units (ICUs).

Methods

All adults admitted to ICUs with dengue virus infection (DENV) at a medical center from July 1, 2015 to December 31, 2015 were enrolled. DENV was diagnosed by the presence of serum NS1 antigen, IgM antibodies to dengue virus, or dengue virus RNA by real-time reverse transcriptase polymerase chain reaction. Demographic data, clinical features, and lab data were collected, and a multivariate Cox model was used to identify the predictive factors for in-hospital mortality.

Results

Seventy-five patients admitted to ICUs with laboratory-confirmed DENV were enrolled (mean age 72.3±9.3 years). The most common comorbidities included hypertension (72.0%), diabetes (43.7%), and chronic kidney disease (22.7%). The in-hospital case fatality rate (CFR) was 41.3%. The patients who died were predominantly female, had higher disease severity at ICU admission, shorter ICU/hospital stay, longer initial activated partial thromboplastin time (APTT), and higher initial serum aspartate transaminase levels. Cardiac arrest before ICU admission (hazard ratio [HR]: 6.26 [1.91–20.54]), prolonged APTT (>48 seconds; HR: 3.91 [1.69–9.07]), and the presence of acute kidney injury on admission (HR: 2.48 [1.07–5.74]), were independently associated with in-hospital fatality in the Cox multivariate analysis.

Conclusion

During the 2015 dengue outbreak in Taiwan, the patients with severe dengue in ICUs were characterized by old age, multiple comorbidities, and a high CFR. Organ failure (including cardiac failure, and renal failure) and coagulation disturbance (prolongation of initial APTT) were independent predictive factors for in-hospital fatality.

Severe forms of dengue fever (DF) are usually considered as a pediatric disease in southern Asia and are graded from dengue hemorrhagic fever (DHF) to dengue with shock syndrome (DSS). However, the age of affected individuals is increasing in Singapore, Thailand, Mainland China, Taiwan and many other countries. Limited data are available on the elderly with DF in intensive care units (ICUs). DF in the elderly is an emerging infectious disease and poses a new clinical challenge to physicians. We enrolled the patients with laboratory-confirmed dengue in our ICU during the 2015 dengue outbreak in Taiwan. These patients were characterized by old age, multiple comorbidities, and a high case fatality rate (CFR). All of the patients were classified as severe dengue, and the in-hospital CFR was 41.3%. Renal failure and cardiac arrest were associated with fatality. In addition to organ failure, initial prolonged activated partial thromboplastin time (APTT) in our study was consistent with an independent predictive factor for in-hospital fatality. Previous studies have also reported that prolongation of APTT is a clinical predictor of dengue virus infection (DENV) or DHF. Our results highlight that APTT prolongation may be a prognostic factor in critically ill adults with severe dengue.

Evaluation of Safety and Efficacy of Salvage Therapy With Sunitinib, Docetaxel (Tyxan) and Cisplatinum Followed by Maintenance Vinorelbine for Unresectable/Metastatic Nonsmall Cell Lung Cancer: Stage 1 of a Simon 2 Stage Clinical Trial. [Corrected]

Current chemotherapeutic regimens for nonsmall cell lung cancer (NSCLC) have reached a plateau over the last few years. Targeted therapy makes use of tyrosine kinase inhibitors (TKIs) to suppress a number of signaling pathways including epidermal growth factor receptor and vascular endothelial growth factor which are active in NSCLC biology. In this study, we used sunitinib, a multi-target receptor TKI, combined with chemotherapy for unresectable/metastatic NSCLC.This open label Simon's 2 stage clinical trial enrolled a total of 6 NSCLC patients who received docetaxel (40 mg) and cisplatin (50 mg) on day 1 of each cycle (14 day interval between cycles) and sunitinib (25 mg qd for 10 days between cycles) for a total of 12 cycles (24 weeks), after which patients received maintenance therapy with vinorelbine (30 mg TIW) until disease progression. The sample size was based on a Simon's Optimal Two-Stage Designs for Phase II clinical trials. The expected response rate was set as 35% for P0 and as 60% for P1. The study was designed for a minimum of 6 patients for first stage and 15 patients until second stage with a significance level alpha = 0.10 and power = 70%. Diagnosis of a poor response in the second of 6 patients in Stage I or seventh of the 15 patients in Stage II would lead to early termination of the trial.The overall response rate was 66.7%. Four patients had an overall survival >60 months. The time to PFS ranged from 3 to 42 months. The combination therapy was well-tolerated.Sunitinib combined with chemotherapy shows promise and warrants further investigation.

A fully integrated nose-on-a-chip for rapid diagnosis of ventilator-associated pneumonia

Ventilator-associated pneumonia (VAP) still lacks a rapid diagnostic strategy. This study proposes installing a nose-on-a-chip at the proximal end of an expiratory circuit of a ventilator to monitor and to detect metabolite of pneumonia in the early stage. The nose-on-a-chip was designed and fabricated in a 90-nm 1P9M CMOS technology in order to downsize the gas detection system. The chip has eight on-chip sensors, an adaptive interface, a successive approximation analog-to-digital converter (SAR ADC), a learning kernel of continuous restricted Boltzmann machine (CRBM), and a RISC-core with low-voltage SRAM. The functionality of VAP identification was verified using clinical data. In total, 76 samples infected with pneumonia (19 Klebsiella, 25 Pseudomonas aeruginosa, 16 Staphylococcus aureus, and 16 Candida) and 41 uninfected samples were collected as the experimental group and the control group, respectively. The results revealed a very high VAP identification rate at 94.06% for identifying healthy and infected patients. A 100% accuracy to identify the microorganisms of Klebsiella, Pseudomonas aeruginosa, Staphylococcus aureus, and Candida from VAP infected patients was achieved. This chip only consumes 1.27 mW at a 0.5 V supply voltage. This work provides a promising solution for the long-term unresolved rapid VAP diagnostic problem.

Treatment outcomes of patients with different subtypes of large cell carcinoma of the lung

BACKGROUND

Although large cell neuroendocrine carcinoma (LCNEC) and lymphoepithelioma-like carcinoma (LELC) are the variants of large cell carcinoma (LCC) of lung, there are few studies comparing them. The aim of this study was to compare the clinical characteristic and treatment outcomes of LCNEC, LELC, and classic LCC.

METHODS

Patients with LCNEC, LELC, or classic LCC were identified in a prospectively collected database, and their data were analyzed.

RESULTS

A total of 46 patients with classic LCC, 30 with LCNEC, and 18 with LELC, who received surgical resection with curative intent, were identified and included in the analysis. Patients with LELC were younger, and the frequency of nonsmokers was greater than in patients with classic LCC or LCNEC. In patients with LCNEC or LELC, most lesions were located on the left side. There were 5 surgical deaths, and the median follow-up time of the surviving patients was 44.1 months. The 5-year disease free survival among the three subgroups was similar (p = 0.601), but patients with LELC had a significantly better overall survival than the other two subgroups (LELC vs classic LCC, p = 0.009; LELC vs LCNEC, p = 0.002). Multivariate analysis showed tumor location site, tumor stage, and LELC were independent prognostic factors of overall survival.

CONCLUSIONS

The clinical manifestations and treatment outcomes of LCNEC, LELC, and classic LCC are different. LCNEC has a poor survival, and survival is not different than that of classic LCC. LELC is associated with younger age and a higher frequency of nonsmokers, and the treatment outcomes are better than those of other subtypes.

Role of right upper mediastinal lymph node metastasis in patients with esophageal squamous cell carcinoma after tri-incisional esophagectomies

BACKGROUND

Whereas standard (infracarinal) mediastinal lymphadenectomy refers to the clearance of lymph nodes in the middle and lower posterior mediastinum, extension along right side of trachea and upper mediastinum is termed extended lymphadenectomy. The benefit of an extended versus standard lymphadenectomy in esophageal cancer is unclear.

METHODS

The clinicopathologic data of 391 patients undergoing tri-incisional esophagectomy (McKeown type) for squamous cell carcinoma between 1995 and 2007 were analyzed retrospectively. There were 136 and 255 patients in the infracarinal and extended mediastinal lymphadenectomy groups, respectively. The outcome of these two groups and the clinical importance of right upper mediastinum lymph node metastases (LNM) were investigated.

RESULTS

Both groups were comparable in clinicopathologic characteristics except tumor length (infracarinal vs extended group, 4.6 vs 5.2 cm, P = .023) and lymph node status. The 5-year overall survival rates were 29.7% and 27.3%, in the infracarinal and extended groups, respectively (P = .065). In the extended group, the factors correlated to right upper mediastinal LNM included neck LNM (hazard ratio [HR] 2.621, P = .029), abdominal LNM (HR 2.218, P = .016), and tumor locating in the upper/middle third of esophagus (HR 2.781, P = .014). The independent prognostic factors for overall survival included right upper mediastinal LNM (HR 1.964, P < .001), lower mediastinal LNM (HR 1.391, P = .039), and abdominal LNM (HR 1.538, P = .006).

CONCLUSION

The procedure of right upper mediastinum lymphadenectomy is not associated with better survival in patients with esophageal squamous cell carcinoma patients; the presence of upper mediastinum LNM predicted poor prognosis.

Lens of controllable optical field with thin film metallic glasses for UV-LEDs

In the exposure process of photolithography, a free-form lens is designed and fabricated for UV-LED (Ultraviolet Light-Emitting Diode). Thin film metallic glasses (TFMG) are adopted as UV reflection layers to enhance the irradiance and uniformity. The Polydimethylsiloxane (PDMS) with high transmittance is used as the lens material. The 3-D fast printing is attempted to make the mold of the lens. The results show that the average irradiance can be enhanced by 6.5~6.7%, and high uniformity of 85~86% can be obtained. Exposure on commercial thick photoresist using this UV-LED system shows 3~5% dimensional deviation, lower than the 6~8% deviation for commercial mercury lamp system. This current system shows promising potential to replace the conventional mercury exposure systems.

Compact light-emitting diode lighting ring for video-assisted thoracic surgery

In this work, a foldable ring-shaped light-emitting diode (LED) lighting assembly, designed to attach to a rubber wound retractor, is realized and tested through porcine animal experiments. Enabled by the small size and the high efficiency of LED chips, the lighting assembly is compact, flexible, and disposable while providing direct and high brightness lighting for more uniform background illumination in video-assisted thoracic surgery (VATS). When compared with a conventional fiber bundle coupled light source that is usually used in laparoscopy and endoscopy, the much broader solid angle of illumination enabled by the LED assembly allows greatly improved background lighting and imaging quality in VATS.

High expression of high-mobility group box 1 in the blood and lungs is associated with the development of chronic obstructive pulmonary disease in smokers

BACKGROUND AND OBJECTIVE

High-mobility group box 1 (HMGB1) is an important mediator in multiple pathological conditions, but the expression of HMGB1 in chronic obstructive pulmonary disease (COPD) has not yet been completely investigated. We aimed to analyze the relationship between HMGB1 expression in blood and lung tissue and the development of COPD.

METHODS

Twenty-eight patients admitted for single pulmonary surgical intervention were enrolled. The expression of HMGB1 in blood and lung tissue was evaluated by enzyme-linked immunosorbent assay analysis and immunohistochemistry stain, respectively. The study patients were divided into smokers with COPD (n = 11), smokers without COPD (n = 8) and non-smoker healthy controls (n = 9).

RESULTS

Smokers with COPD compared with smokers without COPD and healthy controls were older in age, with lower post-bronchodilator forced expiratory volume in 1 s/forced vital capacity (FEV1 /FVC) ratio (63.1 ± 5.5 vs 77.6 ± 3.6 and 84.5 ± 5.8, P < 0.001 and P < 0.001, respectively) and higher levels of plasma HMGB1 (93.2 ± 139.9 vs 7.3 ± 4.8 and 17.0 ± 19.6 ng/mL, P = 0.016 and P = 0.021, respectively). In smokers with COPD, the numbers and portion of HMGB1-expressing cells in epithelium and submucosal areas were significantly increased. Notably, plasma HMGB1 levels negatively correlated with post-bronchodilator FEV1 /FVC ratio (r = -0.585, P = 0.008) in smokers, but not in non-smokers.

CONCLUSIONS

In smokers, high expression of HMGB1 in the blood and lungs is related to the lung function impairment and appears to be associated with the development of COPD.

Surgical outcomes in lung cancer presenting as ground-glass opacities of 3 cm or less: a review of 5 years' experience

BACKGROUND

High-resolution computed tomography (HRCT) has become increasingly popular recently and more pulmonary ground-glass opacities (GGOs) are being identified. However, the treatment for these GGOs remains controversial. The purpose of this study was to retrospectively review the clinical and pathological characteristics and to demonstrate the longterm surgical outcomes in patients undergoing resection for GGOs in our institute.

METHODS

From January 2004 to December 2008, we enrolled 50 patients undergoing resection for solitary pulmonary GGOs of 3 cm or less at Taipei Veterans General Hospital. Patients with a past history of lung cancer, or multiple GGOs at presentation, or GGOs accompanied by a solid component of more than 50 percent were excluded. The patients were retrospectively reviewed and the rate and circumstances of survival were analyzed.

RESULTS

Of the 50 patients, 43 (86%) patients underwent surgery immediately after the GGO lesions were detected by the initial HRCT. Forty-six (92.0%) patients were diagnosed with lung cancer. Of this group, there were 8 (17.4%) adenocarcinomas with lepidic predominant pattern, 13 (28.3%) adenocarcinomas with acinar predominant pattern, and 24 (52.2%) adenocarcinomas with papillary predominant pattern. There was one adenocarcinoma that was mixed with small cell carcinoma. There was no surgical mortality overall, and the 5-year overall and disease-specific survival rates were 97.5% and 100%, respectively.

CONCLUSION

The percentage of malignancy is high in pulmonary GGOs. Surgery results in an excellent prognosis in these patients.

Surgical results of synchronous multiple primary lung cancers: similar to the stage-matched solitary primary lung cancers?

BACKGROUND

Treatment for synchronous multiple primary lung cancers (SMPLC) remains controversial. Some surgeons treat SMPLC like advanced lung cancer, whereas other surgeons treat SMPLC as separate primary lung cancers. In this study, survival of SMPLC patients and matched-stage solitary primary lung cancer (SPLC) patients after surgical treatment were compared.

METHODS

Prospective medical records between 2001 and 2011 were retrospectively reviewed.

RESULTS

A total of 1,995 patients underwent pulmonary resection for lung cancer in a tertiary referral center. Only 97 patients met the modified criteria of Martini and Melamed for SMPLC. The median follow-up time was 38.3 months. The 3-year and 5-year overall survival rates were 83.1% and 69.6%, respectively. In the univariate analysis, males, smokers, and tumor size greater than 3 cm demonstrated significantly worse survival. After multivariate analysis, only tumor size (p = 0.018; hazard ratio 3.199) was identified as an independent predictor of survival. In addition, there was no significant difference in overall survival between the matched-stage SMPLC and SPLC without mediastinal lymph node involvement. Subgroup analysis in the multiple synchronous adenocarcinoma (n = 78) group demonstrated no significant difference between similar and different comprehensive histologic subtyping with respect to overall survival (61.3% versus 68.8%, p = 0.474).

CONCLUSIONS

The surgical results for SMPLC were compatible and acceptable with those for SPLC even with similar histologic subtyping, instead of T4 or M1 stages in the current TNM classification system. Preoperatively, tumor size was the only independent prognostic factor for SMPLC with surgical intervention.

Comparison of survival among neoadjuvant chemoradiation responders, non-responders and patients receiving primary resection for locally advanced oesophageal squamous cell carcinoma: does neoadjuvant chemoradiation benefit all?

OBJECTIVES

While neoadjuvant chemoradiation followed by surgery has been shown to improve the survival of patients with locally advanced oesophageal cancer, it is not known whether neoadjuvant chemoradiation has a beneficial or harmful effect on the non-responders. We aimed to compare the outcomes among neoadjuvant chemoradiation responders, non-responders and patients receiving primary oesophagectomies for resectable locally advanced oesophageal squamous cell carcinoma.

METHODS

Eighty-four non-T1-2N0 oesophageal squamous cell carcinoma patients were included. Thirty-eight patients received primary resection and 46 patients received neoadjuvant chemoradiation. The overall survival of chemoradiation responders (<50% residual tumour), non-responders (>50% residual tumour and those who shifted to definitive chemoradiation instead of surgery due to tumour progression) and patients receiving primary resection were compared. Clinical parameters were also compared between responders and non-responders.

RESULTS

There was no overall difference in survival between neoadjuvant chemoradiation and primary resection groups (2-year overall survival rates: 45.6 vs 54.3%, P = 0.442). In patients receiving neoadjuvant chemoradiation followed by surgery, pathological responders had significantly higher 2-year overall survival rates than non-responders (64.5 vs 38.9%, P = 0.043). While the pathological responders had the highest survival rate, clinicopathological non-responders (pathological non-responders and patients with tumour progression during the neoadjuvant chemoradiation period) demonstrated significantly worse outcomes than those receiving primary resection (32.0 vs 54.3%, P = 0.036). However, none of the clinical parameters, including blood profiles, images and baseline tumour characteristics, predicted the response to chemoradiation before treatment.

CONCLUSIONS

Neoadjuvant chemoradiation non-responders demonstrated no benefit and an even worse outcome compared with those receiving primary resection for locally advanced oesophageal squamous cell carcinoma. However, no significant clinical parameters could be implemented in the clinics to predict the response to neoadjuvant chemoradiation before treatment.

Chemopreventive properties of Peptide Lunasin: a review

Cancer has become one the most common causes of death in developed countries and has been defined as the medical challenge of our times. Accumulating evidence support the notion that prevention can be a major component of cancer control. Chemoprevention, a relatively new and promising strategy to prevent cancer, is defined as the use of natural and/or synthetic substances to block, reverse, or retard the process of carcinogenesis. Plant-based foods, containing significant amounts of bioactive phytochemicals, may provide desiderable health benefits beyond basic nutrition to reduce the process of cancer. In the last few years, proteins and peptides have become one group of nutraceuticals that show potential results in preventing the different stages of cancer including initiation, promotion, and progression. Lunasin is a 43- amino acid peptide identified in soybean and other plants whose anti-carcinogenic activity has been demonstrated both in in vitro and in vivo assays. Moreover, this peptide has been found to exert anti-inflammatory and antioxidant properties that could contribute to its chemopreventive effects. Lunasin's bioactivity and its molecular mechanism(s) of actions are summarized in this review.

Reconstruction after esophagectomy for esophageal cancer: retrosternal or posterior mediastinal route?

BACKGROUND

The aim of this study is to investigate which reconstructive route is most appropriate for patients undergoing an esophagectomy for esophageal cancer.

METHODS

Clinical data on 110 patients were retrospectively collected by reviewing their medical charts. In order to evaluate the effects of adjuvant radiotherapy, patients were interviewed about the adverse side effects they experienced during and after treatment.

RESULTS

The leakage rate was significantly lower in group that received posterior mediastinal reconstruction compared with the group that received retrosternal reconstruction (7.1% vs. 39%, p = 0.01). There were no significant differences between groups in terms of side effects related to adjuvant chemoradiotherapy or radiotherapy. The quality-of-life reports of patients who received adjuvant radiotherapy were not significantly different between the two study groups.

CONCLUSION

For patients with esophageal cancer who undergo an esophagectomy followed by gastric conduit reconstruction, the posterior mediastinal route is superior to the retrosternal route in regard to anastomotic leakage and hospital mortality. Adjuvant radiotherapy did not influence the postoperative functions of the gastric conduit used for reconstruction in either route.

A low-power electronic nose signal-processing chip for a portable artificial olfaction system

The bulkiness of current electronic nose (E-Nose) systems severely limits their portability. This study designed and fabricated an E-Nose signal-processing chip by using TSMC 0.18-μ m 1P6M complementary metal-oxide semiconductor technology to overcome the need to connect the device to a personal computer, which has traditionally been a major stumbling block in reducing the size of E-Nose systems. The proposed chip is based on a conductive polymer sensor array chip composed of multiwalled carbon nanotubes. The signal-processing chip comprises an interface circuit, an analog-to-digital converter, a memory module, and a microprocessor embedded with a pattern-recognition algorithm. Experimental results have verified the functionality of the proposed system, in which the E-Nose signal-processing chip successfully classified three odors, carbon tetrachloride (CCl4), chloroform (CHCl3), and 2-Butanone (MEK), demonstrating its potential for portable applications. The power consumption of this signal-processing chip was maintained at a very low 2.81 mW using a 1.8-V power supply, making it highly suitable for integration as an electronic nose system-on-chip.

Thoraco-abdominal pressure gradients during the phases of respiration contribute to gastroesophageal reflux disease

BACKGROUND AND AIMS

Exaggerated pressure fluctuation between the thorax and abdomen during exercise or with pulmonary disease may challenge the gastroesophageal barrier and allow reflux of gastric juice into the esophagus. The aim of this study was to investigate the pressure differentials in the region of the gastroesophageal junction to better understand the relationship between the thoraco-abdominal pressure gradient and the lower esophageal sphincter (LES) barrier function.

METHODS

We reviewed the esophageal motility and 24-h pH studies in 151 patients with a manometrically normal lower esophageal sphincter who did not have pulmonary disease, history of anti-reflux surgery, hiatal hernia, or ineffective esophageal motility (IEM). Intra-abdominal gastric and intra-thoracic esophageal pressure fluctuations with respiration were measured and the thoraco-abdominal pressure gradients were calculated during both inspiratory and expiratory phases of the respiratory cycle. Predictive factors for an abnormal composite pH score were identified by multivariable analysis.

RESULTS

An inspiratory thoraco-abdominal pressure gradient that was higher than the resting LES pressure was found in 27 patients. In 23 of these patients (85.2%) there was increased esophageal acid exposure (OR 13.5, 95% CI 4.4-41.8). An abnormal composite pH score was predicted by a high inspiratory thoraco-abdominal pressure gradient (P < 0.001), greater fluctuation between inspiratory and expiratory thoracic pressure (P = 0.023), lower LES resting pressure (P = 0.049) and a decreased residual pressure after a swallow induced relaxation (P = 0.002).

CONCLUSIONS

The gastroesophageal barrier function of the LES can be overcome during times when the inspiratory thoraco-abdominal pressure gradient is increased, leading to reflux of gastric juice into the esophagus. This implies that exaggerated ventilatory effort, as occurs with exercise or in respiratory disease, can result in gastroesophageal reflux.

Impetigo herpetiformis with gestational hypertension: a case report and literature review

BACKGROUND

Impetigo herpetiformis (IH) is a rare skin disorder that occurs during pregnancy. It was previously associated with high maternal and fetal mortality and morbidity, but now has a better prognosis.

CASE REPORT

We report a case of a pregnant woman with IH who presented with generalized erythematous pustular eruptions in the 32nd week of gestation. The IH progressed rapidly, and gestational hypertension was observed in the 36th week. The lesions did not subside, despite treatment with corticosteroids and phototherapy. She delivered a healthy male baby via cesarean section in the 37th week. One month after her delivery, her skin returned to normal, except for residual pigmentation, with complete recovery 3 months postpartum.

CONCLUSION

An experienced medical team comprising obstetricians, dermatologists, perinatologists and neonatologists is critical to aggressively treat this life-threatening specific dermatosis of pregnancy and to prevent ensuing complications, such as fluid and electrolyte imbalance, secondary infection and placental insufficiency.

Prognosis of non-small-cell lung cancer with unexpected pleural spread at thoracotomy

BACKGROUND

The aim of the study is to investigate the prognosis of non-small-cell lung cancer (NSCLC) with unexpected pleural spread at thoracotomy.

MATERIALS AND METHODS

We conducted a retrospective review of the clinicopathologic characteristics of NSCLC patients with unexpected pleural spread at thoracotomy in Taipei Veterans General Hospital between January 1990 and December 2008. Inclusion criteria were patients with frozen section of pleural nodules identified as metastatic carcinoma during operation. A survival analysis was done.

RESULTS

There were 138 patients included in this study. The median follow-up time was 19.9 mo. The overall 1, 3, and 5-year survival rates were 72.9%, 26.8%, and 16.6%, respectively. Multivariate analysis showed that main tumor resection and mediastinal lymph nodal involvement (P < 0.001 and 0.002, respectively) were significant predictors for overall survival rate. Patients who underwent main tumor resection and those without mediastinal lymph node metastasis had better outcomes.

CONCLUSIONS

Among the unexpected pleural spread detected at thoracotomy, limited pulmonary resection was an alternative surgical procedure for these patients without mediastinal nodal metastasis.

Effect of dopants on the soft magnetic properties and high frequency characteristics of FeCoBM (M = Ti, Nb, Hf, and Ta) thin films

Effect of dopants on the soft magnetic properties and high frequency characteristics of FeCoBM thin films (M = Ti, Nb, Hf, and Ta) have been studied. For (Fe0.55Co0.45)(100-x)B(x) (x = 5-15) thin films, with the increase of B content, the resistivity was increased because B could decrease the crystallinity of the films. The (Fe0.55Co0.45)90B10 thin film showed the optimum properties, where 4piM(s) = 16.1 kG, H(ce) = 64.2 Oe, H(ch) = 13.5 Oe, H(k) = 310 Oe and p = 338 microomega-cm. To reduce the coercivity of the film, the elements M, including Ti, Nb, Hf, and Ta, were selected to substitute for B in the FeCoB films. It was found that (Fe0.55Co0.45)90B6Ti2Nb2 thin film after annealing at a temperature of 200 degrees C for 30 min showed the optimal properties, where 4piM(s) = 15.8 kG, H(ce) = 4.8 Oe, H(ch) = 3.6 Oe, H(k) = 224 Oe and p = 290 microomega-cm. The theoretically calculated ferromagnetic resonance frequency of the developed films can be higher than 5 GHz.

Magnetic properties of melt spun mischmetals-Fe-Ti-B nanocomposite ribbons

Magnetic properties and phase evolution of melt spun R9.5Fe(bal.)Ti2B10 (R = MM(A), MM(B), MM(C), Pr, Nd, Ce, and La) nanocomposites have been investigated. Based on the results for the X-ray diffraction and thermal magnetic analysis, only 2:14:1 and alpha-Fe phases appear for R = MM(A) and Pr, and an additional Fe3B phase is present for R = MM(B), MM(C), Nd, and Ce. Besides, the uniform fine grain size of 20-40 nm is almost unchanged for the ribbons with various rare earth elements. Accordingly, magnetic properties of MM9.5Fe(bal.)Ti2B10 nanocomposites are mainly dominated by the composition of Mischmetals or the rare earth elements adopted, and are consistent with the outcome for the combinations of magnetic properties of their corresponding R9.5Fe(bal.)Ti2B10 nanocomposites. In this study, the optimum magnetic properties of B(r) = 9.3 kG, (i)H(c) = 12.1 kOe and (BH)(max) = 18.0 MGOe can be achieved for MM(B)9.5Fe(bal.)Ti2B10 nanocomposites. They not only exhibit comparable magnetic properties to the commercial available powders but also reduce the original material cost effectively.

Magnetic properties, phase evolution, and microstructure of melt spun Hf-substituted Sm(Co0.97Hf0.03)(x)Cy (x = 5-9; y = 0-0.1) nanocomposites

Magnetic properties, phase evolution, and microstructure of melt spun Hf-substituted Sm(Co0.97Hf0.03)(x)Cy (x = 5-9; y = 0-0.1) ribbons quenched at the wheel speed of 40 m/s are investigated. X-ray diffraction analysis shows that the main phases existed in Sm(Co0.97Hf0.03)(x) ribbons are 1:5 phase for x = 5-5.5; 1:5 and 1:7 phases for x = 6; 1:7 phase for x = 6.5-7.5; 1:7 and 2:17 phases for x = 8; and only 2:17 phase for x = 8.5-9, respectively. For Sm(Co0.97Hf0.03)(x) (x = 5-9) ribbons, the optimum magnetic properties of B(r) = 5.6 kG, (i)H(c)= 15.6 kOe and (BH)(max) = 7.1 MGOe are obtained for Sm(Co0.97Hf0.03)6.5 ribbons. Furthermore, a slight amount of C addition in Sm(Co0.97Hf0.03)(x) ribbons slightly modify phase constitution and effectively refine the grain size from 200-700 nm for C free ribbons to 10-70 nm, strengthening the exchange coupling effect between magnetic grains of the ribbons. As a result, magnetic properties are further improved. The magnetic properties of B(r) = 6.9 kG, (i)H(c) = 9.2 kOe and (BH)(max) = 10.0 MGOe can be achieved for Sm(Co0.97Hf0.03)7.5C0.1 nanocomposites.

Surgical outcomes in resected non-small cell lung cancer < or = 1 cm in diameter

BACKGROUND

The goal of this study was to investigate the prognostic factors and patterns of recurrence in patients with resected non-small cell lung cancer (NSCLC) < or = 1 cm in diameter.

METHODS

We conducted a retrospective review of the clinicopathological characteristics of 71 patients with NSCLC < or = 1 cm in diameter in Taipei Veterans General Hospital between 1982 and 2007. Overall survival and its predictors were analyzed.

RESULTS

Median follow-up time of the 71 patients was 33.3 months. Complete resection was performed in 68 patients (95.8%) with stage I disease. The 5- and 10-year overall survival rates of patients who underwent complete resections were 81.7% and 44.9%, respectively. There was tumor recurrence in 6 (8.8%) of these 68 patients. Five (9.3%) of 54 patients who underwent standard resection experienced tumor recurrence, but only 1 (7.1%) of 14 patients who received sublobar resection had recurrent disease. The difference was not statistically significant (p = 0.569). Multivariate analysis revealed that sublobar resection (hazard ratio, 5.00; 95% confidence interval, 1.28-20.00; p = 0.020) was a significant predictor for worse overall survival.

CONCLUSION

Survival in patients with NSCLC pound 1 cm in diameter is satisfactory. Sublobar resection, performed in patients unfit for standard resection, is a poor prognostic factor for overall survival.

Prognostic factors of postrecurrence survival in completely resected stage I non-small cell lung cancer with distant metastasis

OBJECTIVE

Distant metastasis after surgical resection is the most frequent cause of death in patients with non-small cell lung cancer (NSCLC). This study aimed to investigate the patterns of distant metastasis and the prognostic factors of postrecurrence survival in patients with resected stage I NSCLC with distant metastases.

METHODS

The clinicopathological characteristics of 166 patients with distant metastases after complete resection of stage I NSCLC at Taipei Veterans General Hospital between 1980 and 2000 were retrospectively reviewed. The patients were divided into two groups according to patterns of distant metastasis (single or multiple organ metastases). Predictors of postrecurrence survival were analysed.

RESULTS

The patterns of distant metastasis included single organ metastasis in 106 (63.9%) and multiple organ metastases in 60 (36.1%) patients. The 1- and 2-year postrecurrence survival rates for those with single organ metastasis were 30.2% and 15.1%, respectively. The most common site of single organ metastasis was bone (32.1%), followed by the brain (29.2%). Multivariate analysis revealed that disease-free interval >16 months (HR 0.534; 95% CI 0.288 to 0.990; p=0.046) and treatment for distant metastasis (including re-operation, chemotherapy and/or radiotherapy) (HR 0.245; 95% CI 0.089 to 0.673; p=0.006) were significant predictors of better postrecurrence survival in resected stage I NSCLC with single organ metastasis.

CONCLUSIONS

A longer disease-free interval is a favourable prognostic predictor for postrecurrence survival in resected stage I NSCLC with single organ metastasis. Treatment for distant metastasis significantly prolongs postrecurrence survival.

The metastatic lymph node number and ratio are independent prognostic factors in esophageal cancer

OBJECTIVE

The current American Joint Committee on Cancer staging system for esophageal cancer is based on lymph node location, irrespective of the number of involved and examined lymph nodes.

METHODS

We enrolled 488 patients receiving primary curative resection without neoadjuvant therapy for esophageal cancer between 1995 and 2006. The importance of total resected lymph node number (TLN) and metastatic lymph node number (MLN) and ratio (MLR) on patient survival was investigated.

RESULTS

The overall 3-year survival rate was 35.4%. The 3-year survival rate was equivalent among patients in N1 (23.3%), M1a (22.0%), and nonregional lymph node metastasis-related M1b (18.5%, p = 0.321). No survival difference was noted between patients with TLN < 15 or > or =15 (p = 0.249). Both MLN and MLR significantly predicted patient survival. The 3-year survival rate was 52.3%, 29.2%, and 8.0% for patients with MLN = 0, 1-3, and > or =4, respectively (p < 0.001). For patients with MLR = 0-0.2 or >0.2, the 3-year survival rate was 28.7% and 9.8%, respectively (p < 0.001). However, survival rate differences were more evident when TLN was more than 15.

CONCLUSIONS

We recommend designating both regional and nonregional lymph nodes as N nodes. MLN and MLR, but not TLN, are prognostic factors in esophageal cancer.

Positron emission tomography-computed tomography in predicting locoregional invasion in esophageal squamous cell carcinoma

BACKGROUND

In order to clarify the role of positron emission tomography-computed tomography (PET/CT) in thoracic esophageal squamous cell carcinoma we investigated its value in predicting locoregional invasion.

METHODS

Forty-five patients receiving curative esophagectomy and lymph node dissection were included. The relationship between PET/CT findings and pathology results were studied. Correlation between nodal uptake and the modified lymph node staging, which is based on number of involved nodes (N0 = no nodes; N1 = 1 to 3 nodes; N2 = more than 3 nodes), was evaluated.

RESULTS

The mean maximal standardized uptake value (SUV(max)) was 5.09 +/- 4.00 in T1, 14.17 +/- 2.46 in T2, 13.32 +/- 3.96 in T3, and 10.37 +/- 1.94 in T4 primary tumor. The SUV(max) was significantly lower in stage T1 tumors than in stage T2 and T3 tumors. For regional nodal involvement, PET/CT findings significantly correlated with pathology results. However, the sensitivity, specificity, and accuracy of PET/CT were only 57.1%, 83.3%, and 71.1%, respectively, and even lower for detecting nonregional lymph node metastasis. When stratified by the modified staging system, the mean SUV(max) was 0.64 +/- 1.60 in N0, 1.43 +/- 2.08 in N1, and 4.67 +/- 4.32 in N2 regional lymph node metastases, and was significantly higher in patients with N2 metastasis than in patients with N0 and N1 metastases.

CONCLUSIONS

Locoregional invasion in esophageal cancer can be predicted by PET/CT. The SUV(max) of the primary tumor helped identify T1 tumor, and the SUV(max) of the regional lymph nodes correlated with the severity of nodal involvement.